<Somatostatin
or Octreotide Not Effective in Decreasing Mortality or Transfusion in
Acute Esophageal Varices Hemorrhage

Question

14 year old boy is admitted to the PICU with acute esophageal varices
hemorrhage on an octreotide drip. Does this therapy decrease
mortality or reduce transfusion requirement?

Clinical
Bottom Lines

Acute variceal hemorrhage in the pediatric population is rare.

Randomized, controlled data regarding the use of somatostatin
or octreotide in the management of acute variceal hemorrhage
are only available in the adult literature.

Somatostatin does not decrease mortality compared with placebo in the
management of acute variceal hemorrhage in adults.1,2

The study summarized suggested an increased transfusion requirement
with somatostatin compared with placebo in the management of acute variceal
hemorrhage in adults. There was significant heterogeneity between studies
with respect to this finding. The value of somatostatin or octreotide
in the management of patients with acute variceal hemorrhage is questionable.1,2

Summary of Key Evidence

86 patients with suspected bleeding esophageal varices and
verified or suspected cirrhosis of the liver were randomized
in a double-blinded, controlled trial to receive somatostatin
or placebo. Placebo and control groups had similar characteristics
at the onset.1

Outcome measures after six weeks were survival, blood transfusions,
episodes of bleeding, days with bleeding, use of Sengstaken-Blakemore
tube, and complication. Analysis was on an intention-to-treat
basis.

No significant differences were found between any outcome
measures between the two groups. There were 16 deaths
out of 42 patients in the somatostatin group compared with
16 deaths out of 44 patients in the placebo group (p=1.00).
There was an average of 8 transfusions per patient given to
patients in the somatostatin group compared with an average
of 5 transfusions per patient in the placebo group (p=0.07).

This study had insufficient power for a type II error of p=0.10.

Additional
Comments

Somatostatin is a 14 amino acid hormone. Octreotide is an
8 amino acid derivative of somatostatin with a much longer half-life.
Both have the same therapeutic properties.

Somatostatin and octreotide reduce portal blood flow and hepatic
venous pressure gradient but the effect on intra-esophageal pressure
is more equivocal in experimental studies.2

Both drugs are well tolerated. The major adverse effect is
hyperglycemia with rare reports of insulin requirement for management.3

The Cochrane Database Review with a meta-analysis of 820 adult patients
also found no difference in mortality with the use of somatostatin
or octreotide vs. placebo (OR 1.04, 95%CI 0.74-1.46). It reported
a positive effect with drug for number of transfusions per patient,
corresponding to 1.2U of blood product saved per patient (95%CI
0.8-1.6). This is likely not a clinically significant effect.2

The use of somatostatin or octreotide in the management of acute
non-variceal hemorrhage appears to significantly reduce the risk
of continued bleeding, but not alter the need for surgery nor decrease
the transfusion requirement significantly. The effectiveness
of the drug was limited to the subgroup with peptic ulcer bleeding.3